Provider Demographics
NPI:1760720858
Name:MICHAELSON, KEVIN ANTHONY (CADC 1)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ANTHONY
Last Name:MICHAELSON
Suffix:
Gender:M
Credentials:CADC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 E BURNSIDE
Mailing Address - Street 2:CODA
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214
Mailing Address - Country:US
Mailing Address - Phone:503-236-2290
Mailing Address - Fax:503-239-8407
Practice Address - Street 1:1027 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1328
Practice Address - Country:US
Practice Address - Phone:503-236-2290
Practice Address - Fax:503-239-8407
Is Sole Proprietor?:No
Enumeration Date:2013-01-23
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)